Five historical innovations that have shaped modern orthopaedic surgery.

Throughout history, many innovations have contributed to the development of modern orthopaedic surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern orthopaedic surgery: X-ray imaging, bone cement, the Thomas splint, the Pneumatic tourniquet and robotic-assisted surgery. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of orthopaedic surgery and their ongoing relevance in contemporary and perioperative practice.

An overview of bone cement: Perioperative considerations, complications, outcomes and future implications.

Polymethyl methacrylate is commonly known as bone cement and is widely used for implant fixation in various orthopaedic arthroplasty and trauma surgery. The first bone cement use in orthopaedics is widely accredited to the famous English surgeon, John Charnley, who in 1958, used it for total hip arthroplasty. Since then, there have been many developments in cementing techniques in arthroplasty surgery. This overview aims to cover the perioperative considerations of bone cement, including cementing techniques, current outcomes and complications such as bone cement implantation syndrome. The overview will additionally consider future developments involving bone cement in orthopaedic arthroplasty.

Prothrombin Gene Mutation as a Teaching Tool: An Autobiographical Case Report.

The prothrombin G20210A factor II mutation carrier status has been reported to cause complications during pregnancy. This report presents the case of a patient diagnosed with heterozygous prothrombin G20210A factor II mutation at 29 years of age during preconception genetic screening. The patient had two uncomplicated pregnancies. The patient underwent laparoscopic cholecystectomy with a complicated postoperative course. The complications included deep vein thrombophlebitis (DVT), portal vein thrombosis (PVT), and pulmonary embolization (PE). The treatment options and contraceptive choices are also discussed in this report. Our report discusses the subsequent risks inherent in a heterozygote following the administration of oral contraceptives, prolonged immobilization related to lower extremity trauma, and extended motor vehicle excursion.

Extended Use of The Spanner® Temporary Prostatic Stent in Catheter-Dependent Men with Comorbidities.

PURPOSE: This US FDA investigational device exemption (IDE) study evaluated the extended use of The Spanner® Temporary Prostatic Stent in catheter-dependent men with urinary retention who were not deemed candidates for corrective surgery but demonstrated bladder contractility. MATERIALS AND METHODS: The Spanner was placed for 3 cycles of 30 days in catheter-dependent men with comorbid conditions, confirmed detrusor contractility, and catheter-associated discomfort. At each visit, postvoid residual, maximum flow rate, international prostate symptom score, quality of life, and adverse events were assessed. Voiding success was defined as PVR ≤ 150 ml at all visits. RESULTS: One hundred seven men were enrolled at 8 US sites; 82/107 (76.6%) completed the trial, and 79/107 (73.8%) successfully maintained PVR ≤ 150 ml for the trial duration. Patients were 77.1 ± 10.6 years old; 63/107 (58.9%) were dependent on Foley and 40/107 (37.4%) on intermittent catheterization for 36.0 ± 39.3 days and 30.2 ± 45.8 days, respectively. 25/107 (23.4%) discontinuations were primarily due to voluntary patient withdrawal 9/107 (8.4%), investigator-initiated withdrawal 8/107 (7.5%), or lack of effectiveness 4/107 (3.7%). During Spanner use, the mean Q max was 11.2 ± 6.6, mean IPSS was 7.5 ± 6.4, and mean QOL was 2.0 ± 1.6. The most prevalent device-related adverse events were asymptomatic bacteriuria 25/107 (23.4%), discomfort 10/107 (9.4%), and urinary urgency 8/107 (7.5%). No device-related serious AEs were reported. CONCLUSIONS: This study demonstrates that catheter-dependent men with sufficient bladder contractility can achieve volitional voiding and successful bladder drainage using The Spanner Temporary Prostatic Stent for extended periods of time.

A case of acyclovir neurotoxicity presenting with atypical cerebrospinal fluid findings.

An 82-year-old man with a history of end-stage renal disease presented with progressively worsening confusion and somnolence for the past 4-5 days. The patient was diagnosed with herpes zoster by his primary care physician 5 days ago and was started on a course of valacyclovir 1 g three times a day (dose not adjusted for renal impairment).A lumbar puncture was performed and cerebrospinal fluid (CSF) studies revealed 37 white blood cells (WBCs)/hpf (100% monocytes), protein 64 mg/dL and glucose 52 mg/dL. He was started on ceftriaxone, ampicillin and acyclovir. MRI of the brain was done and was unremarkable. Acyclovir-induced encephalopathy was high on differential, but his CSF findings were concerning for viral encephalitis. Nonetheless, all antimicrobials were discontinued and he was scheduled for a 5-hour dialysis session. The very next day, he showed immense improvement and eventually recovered completely. CSF PCR tests for both herpes simplex virus and varicella zoster virus came back negative.

Treating male retention patients with temporary prostatic stent in a large urology group practice.

Men with either chronic or temporary urinary retention symptoms are common patients treated in a urology practice. Both indwelling and intermittent catheterization are widely used to treat this condition. These approaches are associated with significant complications including infection and reduced quality-of-life. Infection is a target for quality improvement and cost reduction strategies in most care settings today. We use a temporary prostatic stent (TPS) to address these issues in our practice. In this report, we describe our approach to patient selection, sizing, placement and follow up of 214 TPS placed in 56 men with chronic or temporary urinary retention in an office setting. With the first stent placement, average indwelling time was 27 days. Thirty-two patients had multiple stents placed. Replacement was performed routinely and was generally required because underlying comorbidities precluded surgery. In these patients, an average of six stents were placed (range 2-18) with average dwell times of 31 days. Symptomatic urinary tract infections (SUTI) occurred in only 6 of 214 TPS placements (2.8%), resulting in an incident rate of 0.93 SUTI per 1,000 TPS days. TPS is a safe and efficacious means of alleviating symptoms of urinary retention. TPS does not share the same infection risk profile or quality-of-life drawbacks associated with urinary catheters; this makes TPS use relevant as a urinary catheter alternative or when a urinary catheter is not recommended.

Man's best friend: How humans can develop Dirofilaria immitis infections.

Canine heartworm, Dirofilaria immitis, is a nematode parasite that infects dogs by way of mosquito bite. Rarely, humans play accidental hosts to this parasite and are not a suitable environment for the nematode to live. As the parasite dies in the pulmonary vessels it embolizes the vessels causing infarction and eventual nodule formation in the lungs. In the right clinical context, a nodule can be considered malignant prompting invasive tissue sampling. We describe a case of a 48-year-old man who was found to have multiple asymptomatic scattered pulmonary nodules during imaging workup for an insulinoma. Fine needle biopsy of the largest nodule revealed a necrotic granuloma, lab testing and culture ruled out fungal and bacterial causes. Clinically, this picture was consistent with D. immitis infection.

Life history profiles for 27 strepsirrhine primate taxa generated using captive data from the Duke Lemur Center.

Since its establishment in 1966, the Duke Lemur Center (DLC) has accumulated detailed records for nearly 4,200 individuals from over 40 strepsirrhine primate taxa-the lemurs, lorises, and galagos. Here we present verified data for 3,627 individuals of 27 taxa in the form of a life history table containing summarized species values for variables relating to ancestry, reproduction, longevity, and body mass, as well as the two raw data files containing direct and calculated variables from which this summary table is built. Large sample sizes, longitudinal data that in many cases span an animal's entire life, exact dates of events, and large numbers of individuals from closely related yet biologically diverse primate taxa make these datasets unique. This single source for verified raw data and systematically compiled species values, particularly in combination with the availability of associated biological samples and the current live colony for research, will support future studies from an enormous spectrum of disciplines.

The benefits and barriers to physical activity and lifestyle interventions for osteoarthritis affecting the adult knee.

Osteoarthritis prevalence is increasing, placing greater demands on healthcare and future socioeconomic costing models. Exercise and non-pharmacological methods should be employed to manage this common and disabling disease. Expectations at all stages of disease are increasing with a desire to remain active and independent. Three key areas have been reviewed; the evidence for physical activity, lifestyle changes and motivational techniques concerning knee osteoarthritis and the barriers to instituting such changes. Promotion of activity in primary care is discussed and evidence for compliance has been reviewed. This article reviews a subject that is integral to all professionals involved with osteoarthritis care.

Allopurinol, xanthine oxidase, and cardiac ischemia.

Allopurinol as an effective inhibitor of the enzyme xanthine oxidase (XO) has been used for several decades for the treatment of patients with gout and hyperuricemia. Because the inhibition of XO limits the formation of radical oxygen species as well as uric acid (UA) production, allopurinol has been used experimentally for the treatment of conditions associated with ischemia and reperfusion (I/R) injury.Although there have been many ischemic organs treated in the laboratory with allopurinol, the heart has been of particular interest. Therefore, we emphasize our attention to the administration of XO inhibitors such as allopurinol on cardiac I/R as well as cardiac failure. Experimental data also support allopurinol as a possible consideration for biochemical support after acute myocardial infarction. Anker and associates (Circulation. 2003;107:1991-1997) have observed a direct correlation between uric acid levels and mortality in treated heart failure patients. Anker and associates showed a 100% mortality rate in patients with UA levels 800 micromol/L or less over a period of 3 years. Comparing this to a 27% mortality rate in patients with UA levels 400 micromol/L or less over a period of 10 years, it seems that the suppression of XO activity ameliorates myocardial inefficiency, and poor vascular flow may present innovative contributions to the future treatment of I/R heart failure patients. Our review focuses on the role of allopurinol on ischemic hearts as well as those with added chronic heart failure.

Osteochondral injuries of the foot and ankle.

Osteochondral injuries commonly affect the ankle joint and involve the dome of the talus. This article describes the etiology and pathogenesis of these injuries. Their clinical presentation is described and advice is given on how to diagnose and investigate suspected osteochondral injuries. The various treatment options currently available are briefly reviewed. There is some attempt made to give consensus on optimal treatment of this condition at the present time.

A novel technique of graft passage in arthroscopically assisted posterior cruciate ligament reconstruction.

Graft passage for cruciate reconstruction can be troublesome. Specific to the posterior cruciate ligament, difficulties can arise after tunnel preparation when trying to retrieve the graft at the back of the knee, because of the angles involved. We recommend directing a cable passer through the notch toward the tibial tunnel. Once engaged, a cerclage wire can be passed antegrade into the tunnel. Pituitary forceps can be passed to deliver the wire. The wire is looped around the pull-through suture attached to the graft and is pulled into the notch. This can then be retrieved during femoral tunnel preparation before locking. This technique can be made easier via a mini-medial arthrotomy or careful digital palpation via any posterior incisions used in the acute setting to address other injuries. To remain inside the joint capsule, we advocate the use of image intensification. The extent of soft-tissue dissection and amount of surgical time can be reduced by use of this method, and it should be added to the armamentarium of surgical procedures in existence for graft passage in posterior cruciate ligament reconstruction.

Systems survivor: a program for house staff in systems-based practice.

BACKGROUND: The Systems-Based Practice competency expanded the scope of graduate medical education. Innovative approaches are needed to teach this material. PURPOSE: We have designed and implemented a rotation in Systems-Based Practice focused on the interrelationships of patient care, clinical revenue, and the physician's role within health care systems. METHODS: Experiential learning occurs during a 5-day rotation through 26 areas encompassing the clinical revenue cycle, guided by "expert" staff. Using a reversal of the TV show Survivor, house staff begin conceptually "alone" and discover they are members of a large, dedicated team. Assessment results, including a system knowledge test and course evaluations, are presented. RESULTS: Twenty-five residents from four clinical departments participated in Year 1. An increase in pretest to posttest knowledge scores of 14.8% (p

Multifocal osteonecrosis predominantly affecting the knees secondary to chronic alcohol ingestion: A case report and review.

We present a case of multifocal osteonecrosis secondary to alcohol ingestion in a middle aged lady, after the exclusion of other causal factors. It presented initially with knee pain and subsequently necessitated arthroplasty; other areas became more problematic. This condition is rare and we present a literature review that reveals that after steroids the suspected link to alcohol is not so obvious. A high index of suspicion is required and treatment remains expectant and symptomatic. The role of screening is also discussed.

The potential benefit of thermal shrinkage for lax anterior cruciate ligaments.

Radiofrequency thermal shrinkage of the anterior cruciate ligament (ACL) injured knee is a relatively recent treatment. The purpose of this study was to retrospectively analyse the results in a cohort of 32 patients with a minimum follow-up of 12 months (range 12-37 months). Cases were acute (1) or chronic (31), involving either a native or reconstructed ligament. Native ACL injuries were: lax but intact (12 + 1 acute), partial tears with remaining intact femoral attachment (4) or completely torn and attached to the posterior cruciate ligament (PCL) (6). Reconstructions were: Hamstrings (3), Bone-Patella Tendon-Bone (5) or allograft (1). We also recorded concomitant pathology, function status, Lysholm and Tegner scores and KT2000 values. The procedure was successful in limiting instability overall in 72% (23/32), and in particular 44% of reconstructed ligaments (4/9). There was no correlation of results to the treatment of co-existent pathology. The clinical scores remained high in successful cases although sporting function did reduce by follow-up. We conclude that despite these results the technique is still of value in appropriately selected, counselled and rehabilitated individuals. It is a safe technique that may avoid the necessity to proceed to reconstruction and can be considered as a planned procedure or as an adjunct to other therapy for instability at the time of arthroscopy for other pathology.

Mercury exposure aboard an ore boat.

Two maritime academy interns (X and Y) were exposed to mercury vapor after spilling a bottle of mercury on the floor in an enclosed storeroom while doing inventory aboard an ore boat. During a 3-day period, intern Y suffered transient clinical intoxication that resolved after he was removed from the environment and he showered and discarded all clothing. His initial serum mercury level dropped from 4 ng/mL to < 0.05 ng/mL. Intern X had an initial level of 11 ng/mL, which continued to rise to a maximum of 188.8 ng/mL. He complained of tremulousness, insomnia, and mild agitation and was hospitalized. He had showered and discarded all clothing except his footwear earlier than intern Y. Intern X's continued exposure due to mercury in the contaminated boots during the 2 weeks before hospitalization was presumed to be the cause. Removing his footwear led to resolution of his toxic symptoms and correlated with subsequent lowered serum mercury levels. Chelation was initiated as recommended, despite its uncertain benefit for neurologic intoxication. Mercury is used in the merchant marine industry in ballast monitors called king gauges. New engineering is recommended for ballast monitoring to eliminate this hazard.